Physical examination

The physical examination is typically the first diagnostic measure performed after taking the patient's history. It allows for an initial assessment of symptoms and is crucial for determining the differential diagnoses and further steps. Ideally, a complete physical examination should be performed for every patient. In practice, the physical examination is usually tailored to specific patient concerns. Sensitivity and specificity of physical examination findings vary widely. In some cases, a diagnosis is possible on the basis of the physical examination alone. This article covers the basics of the physical examination and links out to other articles for more specific examinations, including:

• Pediatric history taking and physical examination
• Gynecologic and obstetric history and physical examination
• Mental status examination
• Neurological examination
• Head and neck examination
• Lymph node examination
• Pulmonary examination
• Cardiovascular examination
• Abdominal examination
• Skin examination and nail examination

Objectives

• Determine a working diagnosis or differentials, and further diagnostic and management steps.
• Adjust approach from full to focused physical examination as needed based on medical history, patient condition, and findings.

Preparing for the examination ^[1][2][3]

• Provide optimal conditions for the examination:
  • Find a comfortable and quiet place.
  • Ensure privacy: Ask other patients and possibly even family members (depending on patient preference and extent of exam) to leave the room.
• Disinfect hands prior to touching the patient.
• Introduce yourself and your title and explain the procedure.
• Always address patient by his/her name (ask first if it is unknown).
• During the examination, inform the patient about further steps.
• Examination tools include:
  • Pens
  • Stethoscope
  • Penlight
  • Tongue depressor
  • Reflex hammer
  • If necessary, otoscope and ophthalmoscope

Basic techniques

• Inspection
• Palpation
• Percussion
• Auscultation
• Functional examination

Sequence

Approaches to the physical examination vary greatly and depend on a number of factors, including personal, specialty, and institutional preferences, as well as the reason for the visit or patient's chief concerns, condition, medical history, frequency of past visits, and time available. An example of a full exam sequence could consist of:

• Ask the patient to be seated:
  1. General appearance and vital signs
     • Some physicians begin with examination of the hands so that the patient becomes accustomed to the examiner's touch.
  2. Head and neck examination
  3. Neurological examination
  4. Pulmonary examination
  5. Possibly musculoskeletal examination (depending on patient concern)
• Ask the patient to lie supine:
  1. With upper body at a 30–45° angle
     1. Cardiovascular examination
     2. Peripheral portion of neurological examination (reflexes, muscle tone, peripheral sensation)
  2. Lying flat
     1. Abdominal examination
     2. Possibly musculoskeletal examination (depending on patient concern)
     3. Breast examination as indicated (inspection should have occurred while seated)
     4. Pelvic, prostate, or rectal exam as indicated

The physical examination should be tailored to the purpose of visit, patient history, and allotted time in a focused assessment by body systems.

The following sections provide an overview of all the parts of a physical examination that should be considered, including:

• General appearance
• Vital signs
• Skin and nails
• Head and neck
• Lymphatics
• Heart
• Lungs
• Abdomen
• Pelvic
• Neurological
• Musculoskeletal
• Psychiatric: See mental status examination for more information.
• Breast
• Obstetric: See prenatal care and childbirth articles for more information.

In some cases, more details can be found in the links provided.

• Assess physical, behavioral, and emotional state, including:
  • Physical characteristics and appearance: body type, distinguishing characteristics or abnormal formations/symmetry, development, race, personal hygiene
  • Behavior: alert, active, lethargic, calm, agitated, combative, compliant
  • Wellness: well, unwell
  • Color: rosy, pale, flushed, jaundice
  • Posture and gait

Vital signs

• Temperature
• Heart rate
• Respiratory rate
• Blood pressure
• Oxygen saturation and supplemental oxygen device (see arterial blood gas analysis and pulse oximetry)

Body measurements

• Weight, height, and, possibly, BMI
• Children: head circumference; see also “Normal growth in infants and young children”

• Skin
  • Inspect skin appearance and examine skin lesions as needed, taking notes of location, size, colors, texture, shape, and distribution.
  • See skin examination, benign skin lesions, and classic pathologic hand findings.
• Nails
  • Inspect and palpate nails (fingers and toes) and look for abnormal changes to color, shape, or structures.
  • See nail exam and alterations of the nails for interpretation of findings.

• Head, face, and neck: inspect, palpate head, sinuses, neck, and lymph nodes
• Eyes: pupillary response, ocular movements (H), visual acuity with Snellen chart, fundoscopic exam (see examination of the eye)
• Ears: inspect, palpation, otoscopic exam ± Rinne/Weber
• Nose: inspect
• Throat and mouth: open and say “ahh,” stick out tongue, palpate thyroid gland
• See head and neck examination for more details.

• Examine different locations (cervical, axillary, and groin areas)
• Inspection: look for visible enlargement
• Palpation of lymph nodes for:
  • Swelling
  • Tenderness
  • Mobility
  • Irregularity
• See lymph node examination.

• Auscultation of Aortic, Pulmonic, Tricuspid, Mitral (APTM), and carotids areas
  • Auscultate on the skin rather than clothing!
• Jugular venous pulse (see clinical assessment of central venous pressure)
• Pulses (see pulse examination)
• Edema (pitting vs. nonpitting)
• In cardiovascular examination, percussion and palpation (e.g., point of maximal impulse, heave, thrills) only play a minor role.
• See cardiovascular examination for a thorough examination.

• Inspection: breathing pattern, shape of thorax, sputum
• Palpation: tenderness, symmetry, tactile fremitus (“ninety-nine”)
• Percussion: hyperresonant or dull
• Auscultate (would be enough if the case is not pulmonary)
• Egophony (auscultate with ee-aa)
• See pulmonary examination for a thorough examination.

• Inspection
• Auscultation
• Percussion
• Palpation and rebound
• Check for signs: Murphy sign, McBurney, Rovsing sign, Psoas sign, obturator sign
• Costovertebral angle tenderness
• See abdominal examination.

• Female
  • External genital exam: check for any abnormalities of the vulva, labia (e.g., swelling, irritation, ulcers)
  • Internal genital exam: includes the sterile speculum exam, cervicovaginal swab
  • Bimanual pelvic exam: by introducing two fingers of one hand in the patient's vagina while pressing on the abdomen with the other hand the physician to examine patient's uterus and adnexa (e.g., their localization, size, tenderness during manipulation, presence of masses)
  • Rectovaginal pelvic exam: allows for the palpation of the rectovaginal septum palpation in patients with suspected pelvic masses (e.g., colorectal cancer)
  • For other common instrumental diagnostic procedures used for the examination of an OB/GYN patient, see diagnostic procedures in gynecology.
• Male
  • Inspection
    • Hair pattern or any signs of lice or nits
    • Presence of circumcision (uncircumcised patients should be examined with the foreskin retracted)
    • Lesions, rashes, or edema of the penis, scrotum, or perineum
  • Palpation of penis, scrotum, and both testicles
  • Hernia examination (see palpation of the inguinal canal)
  • Prostate examination (see digital rectal examination)

As a student, you should only perform breast, pelvic, and prostate exams under the supervision of a senior physician!

• Levels of consciousness
• Mental status exam
  • Orientation: name, place, date
  • Memory: recent, distant
  • Concentration: world, naming (show pen), unopened letter on the ground that is stamped and addressed - what would you do?
• Cranial nerve examination
• Sensory function (pinprick, dull, proprioception)
• Motor function (upper motor neuron injury vs. lower motor neuron injury)
• Tendon reflexes
• Coordination (finger-nose, rapid alternating)
• Gait assessment
• Romberg test
• Meningeal signs
• See Neurological examination.

• General considerations
  • The musculoskeletal exam is typically tailored to the patient's concern.
  • Procedures include:
    • Gross inspection
    • Assess mobility (compare to unaffected side)
    • Perform percussion and palpation (tenderness)
    • Assessment of strength
    • See orthopedic examination findings.
• Back/spine
  • Inspect for malalignments (such as scoliosis)
  • Assess spine mobility.
  • Lightly percuss the entire curvature of the spine with the fist.
• Shoulder (see orthopedic shoulder examination)
  • Drop arm test
  • Neer test (supraspinatus/rotator cuff tear)
• Elbow
  • Palpate for lateral or medial tenderness.
  • See elbow dislocation.
• Wrist: Tinel sign, Phalen sign
• Hand (see alterations of the hand)
• Knee
  • Check for edema (tap patella after milking).
  • Anterior/posterior drawer tests
  • Varus and valgus stress test (MCL/LCL stability)
  • See signs of meniscus injury.
  • See knee ligament injuries.
  • See osteoarthritis of the hip and knee.
• Hip
  • Have the patient lie down and perform:
    • Joint ROM (flexion/extension, internal/external rotation, adduction/abduction)
    • Straight leg test
  • For further examination of the hip:
    • See osteoarthritis of the hip and knee.
    • See developmental dysplasia of the hip.
    • See “Clinical features” of hip fractures.

• Inspection
  • Skin changes such as erythema, dimpling, scaling
  • Nipple discharge
• Palpation
  • Breast masses
  • Breast tenderness
  • Performed while the patient is supine and with hands behind the head. Palpate in a concentric circle, verticle strip method, or “spokes of a wheel” method
• Axillary examination: see palpation of the axillary lymph nodes
• For more details: See “Clinical features” in benign breast conditions and breast cancer articles.